1/13/2011

1

Oxygen Use: Recommendations For All Practice Settings

Presented at APTA CSM Feb 10, 2011By

Larry Cahalin, PT, PhD, CCSRohini Chandrashekar, PT, CCSRebecca Crouch, PT, DPT, CCS

Ann Fick, PT, DPT, CCSEllen Hillegass, PT, PhD, CCS

Susan Butler McNamara, PT, MMSc, CCSAmy Pawlik, PT, DPT, CCSChristiane Perme, PT, CCS

Overview of Presentation Introduction & Overview of Evidence Current Guidelines & Legal Issues of O2 Use Basics of O2 Delivery

Pulse Oximetry O2 Delivery Devices

Basics of O2 Use and Titration Of Oxygen O2 use in Acute Care O2 use in COPD and with CO2 retention O2 use in Cystic Fibrosis and Heart Failure O2 use in Interstitial Lung Disease (ILD) and Pulmonary

Arterial Hypertension (PAH) Summary of Recommendations

Objectives Discuss current evidence of use of oxygen in practice including benefits,

precautions and populations that benefit from use of oxygen.

Discuss legal issues with use of oxygen including any limitations in state practice acts.

Define and differentiate the modes of delivery of oxygen as well as use of pulse oximetry

Discuss indications and contraindications for titration of oxygen and populations that should be used with caution.

Identify practical tips with the use of oxygen in the clinic or when patients travel.

Discuss indications for use as well as the similarities and differences of oxygen use for all populations seen by PTs and PTAs.

Summarize recommendations of O2 use in all clinical settings based upon current evidence and provide suggestions for further research

Why a Task Force on O2 Recommendations?

Therapists from every practice setting and every state ask CV & P section for information and help on this issue

Lack of knowledge of evidence on O2 use in all populations

PTs fear legal issues on all aspects of O2 use, especially titration as well as fear with O2 use in COPD and CO2 retainers

Lack of knowledge of evidence and guidelines

Need exists for PTs to have recommendations for their profession

Hypoxemia: What is It?

Hypoxemia is defined as a decreased partial pressure of Oxygen (PaO2) less than 60 mm Hg or with an SpO2< 90%

Normal ABG values:

pH 7.35-7.45

pCO2 35 45 mm Hg

PO2 80 100 mm Hg

HCO3 22-26

As PaO2 decreases, SpO2 decreases

Hypoxemia: Causes & Examples

Causes of Decreased PaO2 include:

Alveolar hypoventilation

Clinical example: atelectasis secondary to post op thoracic or abdominal pain

Decreased ventilation (either decreased volume or decreased rate)

Clinical example: decreased volume inability to breathe in adequate volume due to pleural effusion or pulmonary edema

Clinical example: decreased rate sedated or comatose causing decreased repiratory rate

1/13/2011

2

Hypoxemia: Causes and Examples

Ventilation perfusion mismatching

Clinical example: Pulmonary embolus or patient with poor cardiac output

Low inspired partial pressure of oxygen

Clinical example: high altitude

Impaired diffusion across alveolar-capillary membrane

Clinical example: interstitial edema, pulmonary fibrosis impairing diffusion across alveolar wall

Shunting

Clinical example: Pulmonary embolus, emphysema

Hypoxemia: Consequences

Hypoxemia has several physiologic consequences:

As PaO2 falls below 55 mm Hg; marked rise in VE (Minute ventilation) with fall in PaCO2

Peripheral vascular beds dilate causing compensatory HR rise (tachycardia) and Cardiac Output increase to increase O2 delivery

Regional pulmonary vasoconstriction occurs due to alveolar hypoxia

Erythropoietin secretion increases: increase in erythrocytosis and increase in O2 carrying capacity

Kim 2008 Proc Am Thor Soc

Hypoxemia: Long term effects

Polycythemia

Pulmonary hypertension

Right ventricular failure (cor pulmonale)

Chronic hypoxemia with cor pulmonale results in poor prognosis: increased mortality (32-100%) *

Cellular changes: Mitochondrial function declines

Anaerobic glycolysis occurs

Lactate/pyruvate ratio increases* Jones 1967, Boushy 1973

Hypoxemia: Long term Clinical Manifestations

Impaired judgment at low levels of hypoxemia Progressive loss of cognitive and motor functions Loss of consciousness with severe hypoxemia Other

Headache Breathlessness/ severe dyspnea Palpitations Angina Restlessness Tremor

Manning 1995, Lane 1987,

Criner & Celli 1987

Oxygen Use:Short Term and Long Term

Short Term Effects of O2

Improves breathlessness with exercise in COPD patients Improves exercise tolerance in those with mild, moderate or

severe hypoxemia w/exercise Proposed Mechanisms:

Decreased VE (Swinburn 1991 Am Rev Resp Dis) Decrease in dynamic hyperinflation (ODonnell 2001) Alleviation of hypoxic pulmonary vasoconstriction (Dean 1992) Improvement in hemodynamics (Dec PVR, Inc CO) (Dean 1992) Increase in O2 delivery (Morrison 1992) Improvement in ventilatory muscle function (Bye 1985) Altered ventilatory muscle recruitment (Criner & Celli 1987) Reflexive inhibition of central ventilatory drive ( Manning 1995) Decreased perception of dyspnea (Lane 1987)

1/13/2011

3

What are Indications for Short Term Oxygen Therapy?

PaO2 < 55 mm Hg or SpO2 < 88%

PaO2 55 mm Hg but 59 mm Hg and additional diagnoses (PAH, cor pulmonale)

PaO2 60 mm Hg or SpO2 90% but patient desaturates during activity: should use short term O2 with all activities

Kim 2008 Proc Am Thor Soc

Effect of LTOT

Early non-controlled studies: Reduction in mortality in COPD, cor pulmonale and those

with severe hypoxemia with use of continuous O2 7-41 mos.

Two landmark prospective controlled studies Nocturnal O2 Therapy Trial (NOTT: Ann Intern Med 1980)

Continuous O2 versus 12 hrs Nocturnal O2

Mortality was > for nocturnal O2 vs. continuous O2

British Medical Research Council (MRC) Long Term Domiciliary O2 Therapy Trial (Lancet 1981)

Trend that LTOT prevented progressive decrease in PO2 and increase in pulm vascular resistance without increase in PCO2

LTOT

Conclusions from 2 studies (population was severely hypoxemic with elevated HCT, elevated PA pressure and Respiratory acidosis

Nocturnal O2 is better than NO oxygen therapy

Continuous O2 better than nocturnal O2 therapy

No studies have shown benefit with mild or moderate hypoxemia

No studies have shown benefit when O2 prescribed for exercise-induced O2 desaturation

Indications for Long-Term O2 Therapy

Kim 2008 Proc Am Thor Soc

Current O2 Guidelines

Clinical Practice Guidelines Oxygen Therapy for Adults in the Acute Care Facility2002 Revision and Update AARC

Australian and New Zealand Guidelines for management of COPD 2009 ((Abramson; AM Lung Assn 2009)

Legal Issues with O2 Use

APTA Legislative Department knows of no state that has any limitations on Physical Therapists in use of or titration of Oxygen

Oxygen is a DRUG and requires a prescription for its use.

Oxygen order should be written based upon SpO2 and not Liters/minute.

Always check standing orders or patients specific orders

Desire order to be written: Keep SpO2 90 or 88%

Order may be written 2L/min OR SpO2 90 or 88%

One State: Connecticut has new changes in their law for use of O2 in hospitals

1/13/2011

4

PT State Practice Acts

Physical therapy practice acts and physical therapy board regulations are SILENT on the administration of oxygen. However, some state/jurisdiction licensing authorities have provided official interpretive opinions/statements on this issue. Check with your state/jurisdiction licensing authority to determine if your state board has an official statement or opinion regarding the administration of oxygen. To contact your state licensing board, follow this link: http://www.fsbpt.org/licensing/index.asp.

APTA Position Statement

PHARMACOLOGY IN PHYSICAL THERAPIST PRACTICE HOD P06-04-14-14 (Program 32) [Initial HOD 06-89-43-89] [Medications in the Provision of Physical Therapy] [Position]

Physical therapist patient/client management integrates anunderstanding of a patients/clients prescription and nonprescription medication regimen with consideration of its impact upon health, impairments, functional limitations, and disabilities.

The administration and storage of medications used for physical therapy interventions is also a component of patient/client management and thus within the scope of physical therapist practice.

Physical therapy interventions that may require the concomitant use of medications include, but are not limited to, agents that:

Promote integumentary repair and/or protection Facilitate airway clearance and/or ventilation and respiration Facilitate adequate circulation and/or metabolism Facilitate functional movement.

Guide to Physical Therapist Practice

APPENDIX 1: Guide to Physical Therapist Practice

Prescription, Application, and as Appropriate, Fabrication of Devices and Equipment Interventions Prescription, application, and, as appropriate, fabrication of devices and equipment may include:

Supplemental Oxygen

Connecticut Law

Sec. 80. (NEW) (Effective October 1, 2010) A hospital, as defined in section 19a-490b of the general statutes, may designate any licensed health care provider and any certified ultrasound or nuclear medicine technician to perform the following oxygen-related patient care activi